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1 We can help you get there from here.

2 There is no cure for obesity, however, there are effective tools to treat the disease. At the Bariatrics Center, our goal is to help you find the best combination of tools to achieve optimal health at any size through weight management and treatment of related health conditions.

3 Medically Supervised Weight Loss It is possible to achieve and maintain a healthier weight. Sustained improvement to quality of life and weight management requires a total commitment to improved health and wellness. Optimal health can be achieved through a variety of therapies and lifestyle changes. The center offers behavioral change support in addition to medical and surgical options to help you lose weight and get healthier. Our staff welcomes patients aged 16 and older with a body mass index greater than 27 or with metabolic syndrome to make an appointment. Patients with diabetes or at risk for developing diabetes (i.e., weight around the middle of their bodies or mid-life weight gain), are encouraged to visit. Candidates for the medically supervised weight loss option typically have a body mass index (BMI) over 27 and: have health problems related to their weight are interested in using diet, exercise and medication to achieve a healthy weight need to lose weight before being eligible for bariatric surgery A medically supervised weight loss program and maintaining a healthy weight requires a complete lifestyle change in order to be successful. Lifestyle changes always involves behavior changes such as redefining a relationship with food and goal setting, nutrition education, exercise and support counseling. A medically supervised weight loss program may include meal replacements and medications ordered by the doctor. Through group and individual classes, our team of registered dietitians, exercise specialists and psychologists will work together to help you stay focused and committed to your health care goals.

4 Nutrition Registered dietitians with certification in diabetes education provide patients with the tools needed to make lifestyle changes. Individual sessions and group classes address portion control, fat and salt content and the importance of protein in a diet. Behavioral Changes Counseling and goal-setting help patients improve their quality of life. Psychologists work with each patient to identify and understand their relationship with food and provide healthy coping advice on how to change that relationship for long-term weight management success. Physical Activity Research proves daily physical activity has an impact on metabolism and weight management. Exercise specialists develop an activity plan that is safe for each patient. Group activity classes are offered in the clinic with special focus on resistance training and moderate aerobic exercise. Medication Modification Up to 10 percent of weight gain can be caused by medicines taken for chronic health issues. There are several medical conditions that are associated with weight gain: Diabetes Pre-diabetes Weight Loss Medications If we are able to determine that weight loss medications should be part of your individual plan, we will conduct a full exam and prescribe weight loss medicine to be used in phases of treatment. All medicines may not be appropriate for everyone. A plan tailored for you will be suggested. Traditionally, medical weight loss programs were limited to three to six months the Federal Drug Administration (FDA) only approved medication use for three months. Recently, however, the FDA has approved several medications for longer use. The first goal of taking weight loss medication is to prevent further weight gain. The second goal is to reduce five to 10 percent of total body weight for the long term. If five to 10 percent weight loss is reached in six months, the medications will continue for the long term. During your visits, our physicians will discuss medication use and possible side effects. Other goals include: Decreasing waist size Improving blood pressure reading Lowering blood sugar levels Improving cholesterol levels Not all patients respond to medications. The medications will be discontinued if weight and health goals are not met. Weight regain may happen when you no longer take these medications. Polycystic ovary syndrome High blood pressure High cholesterol levels Depression Irritable bowel syndrome As part of the medical supervision of weight loss, our team will review the medications you are currently taking and identify if any of them are causing you to gain weight. We will suggest a switch in medicines, if possible.

5 Surgical Weight Management Weight loss surgery is an option and an effective tool for weight management. It is not an ultimate solution and requires a lifetime commitment to lifestyle change. Patients who elect to have weight loss surgery will also attend programs related to physical activity, nutrition and behavior change. In most cases, surgical candidates will also participate in medically supervised weight loss. The Bariatrics Center received the American Society for Metabolic and Bariatric Surgery (ASMBS) Center of Excellence designation in This designation recognizes surgical programs with a demonstrated track record of favorable outcomes in bariatric surgery. The most experienced and best-run bariatric surgery programs have much lower rates of complications. To earn a Bariatric Surgery Center of Excellence designation, the hospital must perform at least 125 bariatric surgeries annually. At The Nebraska Medical Center, a team of two bariatric surgeons offer several surgical weight-loss options, both malabsorptive and restrictive. The laparoscopic Roux-en-Y gastric bypass (RYGB) is a surgical procedure that alters the process of digestion. This procedure is both malabsorptive and restrictive. It is malabsorptive because the procedure involves bypassing part of the small bowel resulting in fewer calories and nutrients being absorbed. It is restrictive because it involves creating a small stomach pouch that restricts the amount of food that can be eaten at one time. This surgery can result in twothirds of extra weight loss within two years. While malabsorptive procedures produce greater weight loss than restrictive procedures, they also carry more risk for long-term nutritional deficiencies. The laparoscopic sleeve gastrectomy surgery promotes weight loss by removing three-quarters of the stomach. The size of the stomach is reduced by 75 percent, resulting in the ability to hold only two to five ounces of food. This promotes a feeling of fullness with smaller amounts of food resulting in a reduced daily caloric intake. There is minimal risk of nutritional deficiencies. The laparoscopic adjustable gastric band procedure is also referred to as laparoscopic adjustable gastric banding. This procedure is restrictive and does not involve any stapling or changing the gastrointestinal tract. This safe and minimally invasive bariatric procedure promotes weight loss through reduced food intake. A silicone ring is placed around the stomach. Tubing is connected to the ring and is placed beneath the skin during surgery. This allows the surgeon to increase or reduce the size of the ring to better promote successful weight loss. There are currently two laparoscopic adjustable gastric bands in the United States: The Lap-Band and The Realize Band. The Bariatrics Center offers both options. The biliopancreatic diversion with duodenal switch is an aggressive surgery that changes the normal process of digestion. The sleeve gastrectomy is combined with a very extreme bypass. Food bypasses most of the small intestine and fewer calories are absorbed. For patients who had weight loss surgery in the past and experienced complications or did not achieve desired goals, revision surgery options are available.

6 Our Team Obesity specialists guide each patient through their weight loss journey, addressing unique challenges they face along the way. This approach helps patients achieve lasting lifestyle changes and successful management of a healthy weight. Birgit Khandalavala, MD OBESITY MEDICINE SPECIALIST Vishal Kothari, MD BARIATRIC SURGEON Cori McBride, MD, FACS, FASMBS BARIATRIC SURGEON Emily Rossman, PA-C Physician Assistant Sheli Wilkinson, PA-C Physician Assistant Melissa Monzu-Sparks, RN, BSN, CBN Nurse Coordinator Linda Neumann-Potash, RN, MN, CBN Nurse Coordinator Karen Sater RN, BSN Nurse Coordinator Nessie Ferguson, MS, RD, LMNT, CDE Medical Nutrition Therapist Megan Sitz, MPA, RD, LMNT Medical Nutrition Therapist Kim Vacek, PhD CLINICAL Psychologist Kristina Volkmer, MPH, ACSM, HFS Exercise Specialist Jamiela McMillian Insurance Coordinator

7 Considerations Cost of Obesity You have a choice between living with obesity and undergoing medical or surgical treatment. A barrier for most patients struggling with obesity is the cost of the treatment. With economic concerns increasing, obesity treatment may seem like a luxury. When considering the actual cost of treatment, it is important to factor in the comparatively higher costs of obesity and obesity-related complications. Lost wages and increased expenses are an often overlooked result of obesity. According to the National Institute of Health, those who are obese miss more work on average and spend more on gasoline and food each year. The Center for Disease Control and Prevention reports in 2008, medical costs associated with obesity were estimated at $147 billion; the medical costs for people who are obese were $1,429 higher than those of normal weight. Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer, some of the leading causes of preventable death. For these reasons and several other, obesity and related conditions often result in higher health insurance premiums and higher life insurance premiums. Over a lifetime, medications and treatments for high blood pressure and diabetes management can cost more on average than a patient s out-of-pocket cost for obesity treatment. A single treatment for a major complication of high blood pressure, such as heart attack, stroke, atherosclerosis, gallbladder disease and other conditions, often costs more than obesity treatment in some cases, twice as much. Clinic Space The Bariatrics Center is designed to make complete care a convenient reality for our patients who struggle with mobility. Dedicated professionals see patients in one location that is conducive to making the most of a patient s appointment. Private entrance Convenient parking 5,650 total sq. ft. 6 exam rooms Consultation room Classroom for group meetings Patients feel confident to make positive changes for their health when visiting a clinic featuring sizeappropriate accommodations. Doorways Chairs Examination rooms and tables Restrooms Operating tables and equipment Insurance Criteria Some insurance plans offer medically supervised weight loss and bariatric surgery as a covered benefit. If it is a covered benefit, the requirements for authorization vary greatly depending upon the different companies and plans. Some elements we have found common with insurance requirements for surgery include: Up to six months of documented attempts at medically supervised weight loss Submitting a weight history for the past several years Psychiatric evaluation Nutrition evaluation Chest X-ray Electrocardiogram (EKG) Blood tests The Bariatrics Center will work with you to determine if bariatric surgery is a covered benefit under your specific insurance plan. Medicare and Medicaid usually cover bariatric surgery if the procedure is deemed medically necessary. The Nebraska Medical Center offers package rate discounts for patients who do not have insurance coverage.

8 The Bariatrics Center at The Nebraska Medical Center wants to make your next appointment with us as convenient as possible. Please take a moment to review the following information to more easily guide you to our location. Building: University Tower, 2nd floor SADDLE CREEK ROAD DEWEY AVENUE N THE NEBRASKA MEDICAL CENTER CAMPUS Where to park: The Bariatrics Center has eight parking stalls at its entrance. If full, complimentary valet parking is available in the Durham Outpatient Center circle drive. Selfparking is available in Green Parking located on the west side of the circle drive. 45TH STREET GREEN PARKING DURHAM OUTPATIENT CENTER PARKING SPECIALTY SERVICES PAVILION BARIATRICS CENTER EMILE STREET 42ND STREET Directions: The drive to the Bariatrics Center is located on the right side of the Durham Outpatient Center circle drive. There is a covered driveway just past the Specialty Services Pavilion. Mailing address: The Nebraska Medical Center Omaha, NE PH: FX: E: NebraskaMed.com/BariatricsCenter

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